The Nation, 15 December 2004

RX Files: What to do if the condom breaks

Every infectious disease specialist in Bangkok has received calls, usually in
the middle of the night or early morning, from emergency-room residents at
private hospitals who are confronted by an anxious patient who had just realised
that he had unprotected sex and may have been HIV-infected.

The usual story is that “My condom broke” or “I was too drunk to think first”.
The partner usually comes from a bar or massage parlour. High risk behaviour,
for sure! What to do?

Recommendations from public-health authorities are often unclear, but always
there is a full month of anti-HIV drugs if there is real risk of infection.

Differences lie in how to determine the real risk in such situations. The
decision to treat or not is an emergency, since the drugs must be started as
soon as possible, and no later than 72 hours after exposure.

Is such treatment really effective and worth the cost and discomfort, since all
of these drugs have adverse side effects?

Obviously, credible animal experiments are near impossible to do since Aids is a
human disease and animal studies may not be applicable. However, studies of HIV
post-exposure prophylaxis (PEP) have been performed in hospitals where doctors
or nurses obtained nicks or cuts by possibly infected tissue or
fluid-contaminated instruments.

Most of these have been promising, but it was never certain that the recipients
had actually been infected.

A few years ago, a child in Europe received an emergency blood transfusion,
which within hours was known to have come from an HIV-infected donor. PEP was
immediately applied and the child remained free of HIV.

One problem for the physician to evaluate is the extent (risk) of actual
infection and how to balance this against the cost and adverse side effects of
the drugs.

Most patients tend to minimise the exposure, partly as self-deception and partly
being unwilling to admit that they’d been stupid. Here’s where the broken-condom
story comes in.

How many condoms actually break? The quality ones undergo rigid pressure and
friction tests.

The involved sex worker almost always tells the customer that she or he had
regular HIV tests, which were negative, and that condoms are used in all
encounters.

Hard to rely on, so what should be done?

Most patients know where they met their partner and can be told to go back
there, find that person and pay them whatever it takes to have an HIV test.
These are available at all local hospitals and results should be back in
minutes.

If the partner’s test is negative, the risk is significantly reduced. The sex
partner may still be in the “window period” of HIV, where infection has just
taken place, and the test is still negative because antibodies have not yet
formed.

This is a time when a person can be infectious but has a negative antibody test
to HIV.

Doing a viral load test (PCR) might be a theoretical solution, but this test is
not 100-per-cent reliable and not readily available and takes several days – too
long, since starting PEP is not effective after 72 hours post-exposure.

The patient should be informed of this smaller risk and given the choice of
deciding whether he wants PEP, even though the partner’s HIV antibody test was
negative.

Failure to get an HIV test from the partner, and the exposure being deemed
significant, mandates PEP. A pre-treatment HIV and syphilis test is then done
and the patient evaluated for other diseases and treated for any suspected STDs.

He or she is then given a prescription for anti-HIV drugs. The usual drugs
prescribed in Thailand are Combid (Lamivudine and AZT) with a third drug Stocrin
(Efavirenz).

Combid is a fixed combination drug that should not be used if the patient’s
weight is less than 50 kilograms. A one-month supply would cost approximately
Bt16,000 from a Bangkok private hospital pharmacy.

GPO-VIR (a combination of three drugs) should not be used for PEP because it
contains Nevirapine and is designed for long-term treatment.

There is still controversy whether two or three different drugs should be
prescribed. The UN stocks an HIV-PEP kit that contains only two drugs to be
taken for five days as well as contraceptive pills.

This makes little sense unless the patient consults a competent doctor before he
runs out of medication or is able to determine that there was no risk of
infection.

All of the anti-HIV drugs have adverse side effects, consisting of dizziness,
numbness, depressions of the white blood-cell count and gastrointestinal
reactions, as well as occasional drug rashes. However, most patients tolerate
them.

HIV and syphilis tests should also be carried out and repeated after completion
of PEP. The patient must be given a letter for his personal doctor detailing the
nature of PEP and reasons for starting it.

It’s obviously far better to avoid being in such a situation.

________________
Dr Wilde is attached to the Queen Saovabha Memorial Institute, Thai Red Cross
Society.

Cross posting from HIV-News-AsiaPacific@...
[hiv-news-asiapacific] No 416 – China, Singapore and Thailand (17 December
2004). Thailand